Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Thursday, October 30, 2014

One challenge of being a farmer is that the animals, plants and infrastructure need you 24x7x365. This Fall, I’ve had to travel to China (last week) and will be in Europe (London, Berlin, Copenhagen, and Amsterdam) next week.

Last weekend was filled with catchup for the time missed and preparing for the time to be missed.

Luckily, the farm was buzzing with activity - my daughter and her partner David, David’s parents,
and Kathy were all able to join me for farm work. Our tasks were

1. Crush 450 pounds of apples. We made 3 batches of hard cider, two of which will be for drinking and one of which will be cider vinegar for next year’s Unity Farm pickles. Our small batch methods are labor intensive but we have total control of the process, ensuring a perfect blend of apples - sweet, tart, aromatic, and astringent. This crush involved a combination of Spencer, Golden Delicious, Baldwin, Macoun, McIntosh, and Northern Spy. I've moved the cider to our mud room since the cold nights could result in a stuck fermentation.

2. Plant 4000 ginseng seeds and 100 ginseng roots in 1000 square feet of forest. American Ginseng (Panax quinquefolius) is a tricky plant to grow given its unique habitat requirements - a forest slope of 10-25% grade, covered in maple/oak/ash, with 70% shade, in moist leaf humus that is not too moist. I raked a 1000 square foot area of the forest, clearing rocks and roots, then placed the roots at a 30 degree angle to the surface, cutting a v-shaped trench with a shovel. I created a template to plant 4 seeds per square foot over the area. Then we spread 50 pounds of gypsum over the plantings, to add calcium, and covered the soil with 3 inches of leaf mulch. We should see ginseng sprouts in the spring, and have harvestable roots in 6-8 years. Why do this? Part of goal at Unity Farm is forest farming with ginseng, paw paw, black cohosh, goldenseal and other challenging crops as part of permaculture - sustainable crops that have resale value.

3. Plant 600 cloves of garlic - every October we plant hard necked garlic (about 10 different varieties) outdoors so that it can set roots, over winter, and the begin growing as soon as the Spring thaw arrives. We harvest garlic every July and use it in the majority of our cooking/canning. This year we created 7 beds and used a template to set the cloves in perfect 6 inch rows, 2 inches deep. When then covered the beds with salt marsh hay to keep digging animals out and heat/warmth in.

4. Pick raspberries, turnips, daikon, beets, and peppers - all our crops are mature at this point and needed to be picked before the first freeze. We picked a bucket of raspberries, a bushel basket of turnips, a picking box of daikon, an armful of beets, and a double peck of peppers. Kathy combined fresh daikon, Japanese mibuna greens, and Japanese chrysanthemum leaves into a wonderful daikon soup pictured below. The mushrooms continue to fruit and many of our Shitake logs are covered with emerging fungi. The meadows are filled with shaggy manes, wine cap, and champignons. Pictures are below

5. Herd health - all the animals received their inoculations and we released our final flock of 8 week old guineas. We have 68 to overwinter, so I built extra roosts in the coop. Our 50 bird coop can now accommodate 80 birds and our multiple generations of guineas have bonded together as a single flock. The mornings are crisp and the compost piles are steaming

At the moment, the farm is entirely ready for my absence next week. The plants and animals are prepared for the possibility of snow and the harvest is complete, although we’ll continue to grow greens for the next few months. 2014 may very well be the last time I accept extensive foreign travel commitments. Occasional trips are fine, Skype is better, and the farm needs my nights/weekends.

ONC has a served as a catalyst, accelerating the adoption of electronic health records by hospitals and eligible professionals. Guided by the certification regulation, EHRs now include robust interoperability for public health reporting, transition of care exchange, lab result incorporation, patient/family engagement and quality data submission.

We’ve achieved a new baseline that did not exist 4 years ago.

Now it’s time for the private sector to step up and lead the charge on the next generation of interoperability - query/response based on FHIR, OAuth2/Open ID, and REST. We need two implementation guides - one for document level exchange and one for data element exchange of the Meaningful Use Common Data Set (see the last page of this document)

A coalition of the willing - vendors, HL7, providers, program management, and champions from the private sector can keep the momentum going as we all drive to a new set of FHIR specifications in 2015 - a second Draft Standard for Trial Use based on lessons learned with the first draft standard.

Over the past few days, I’ve seen new energy and enthusiasm for accelerating interoperability, following the roadmap described by the Jason Task Force.

Rahm Emanuel said “You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before.”

The combination of change at ONC, the Jason Task Force report, and new private sector urgency for interoperability is a perform storm for innovation

I think the weeks ahead will be filled with rich discussion about how all stakeholders can unify to accelerate the efforts already in progress. It’s truly time for a new optimism

Thursday, October 23, 2014

While I was in China at the beginning of the week, Kathy maintained the farm and all its activities.

To prepare for Monday’s night’s frost, she picked all the mushrooms from our Shitake logs. Subtypes Miss Happiness, Native Harvest, and Night Velvet are all fruiting in large quantities. We’ve developed Unity Farm branded packaging using recyclable cardboard containers and a small amount of perforated shrink wrap. Kathy has been delivering mushrooms to local farm stands in my absence.

Before my departure I picked another peck of peppers, so we now have a pair of pepper pecks which Kathy chose to pickle. She used our homemade apple cider vinegar and this simple recipe

On last week’s flight to Washington I read a great book about farming in the forest. Since Unity Farm is about half forest, the notion of planting paw paw seemed very appealing. So, this weekend we’ll plant paw paw and pack the pair of pickled pepper pecks.

Forest farming in the Northeast can also include American Ginseng, which although rare, grows near spicebush and jack in the pulpit in the Unity Farm forests. Kathy ordered 75 one year old ginseng plants and 500 seeds which will plant in 5 test areas around the forest - north woodland, mid woodland, south woodland, north orchard, south orchard. We’ll watch their growth carefully and then add more ginseng to the successful areas. Ginseng is a slow grower and we’ll have to wait 6-8 years to harvest mature roots.

Now that Unity Farm is built, we’re entering the phase of daily operations - actively farming the forest, managing the trails, inspecting the bees, planting the hoop house, pressing cider, and caring for the animals. Our to do list looks like this

The path from farm to table is a daily process, always focused on the future harvest and working backwards to the tasks of today. The leaves are falling and the seasons are changing fast. The approaching winter will give us time to catchup on indoor tasks, ordering seeds for next year, and reflecting on our lessons learned.

Wednesday, October 22, 2014

On Monday and Tuesday I met with government, industry, and academic stakeholders in Qingdao and Shenzhen China to discuss healthcare technology, patient empowerment, and process improvement in the rapidly expanding Chinese healthcare system. Here's a photo of my visit to a hospital pharmacy in Shenzhen, dispensing ginseng and ling chi mushrooms.

Over the past few years, I’ve watched the Chinese government gradually change policy - from promoting a fully public healthcare system, to limited pilots of private facilities, to embracing public/private partnerships.

Foreign entities can now directly invest and operate joint venture hospitals in China, while Hong Kong and Macau based investors can own and operate hospitals in selected cities.

China faces the same challenges as the US and other industrialized nations - an aging society, increased demand for care, a limited supply of qualified professionals, shrinking budgets, and the need to improve quality.

I outlined a 5 fold approach for China

*Innovation in healthcare technology - universal adoption of EHRs, health information exchange, big data analytics, cloud delivery of services, wearables/mobile for patient/family engagement
*Education/Culture of Quality - ensuring every clinician has access to best practices and feedback on the quality of their practice
*Reputation building - creation of a regional center of excellence well known for outcomes, great teaching, and cutting edge research
*Recruitment of mentors, mid career professionals and early achievers - to foster a supportive community of practice
*Public Health/Health Services research - to provide every clinician with the tools needed to support continuous wellness , population health, and care management.

As the American century draws to a close and China becomes the world’s strongest economy, collaboration between the US and China in the science of healthcare delivery will have mutual benefits.

As I told the mayor of Shenzhen (below), my wife is Korean, and based on my love of the Far East, I am an Asian at heart.

I look forward to ongoing collaboration which improves the quality, safety, and efficiency of healthcare in China.

Monday, October 20, 2014

Over the past several years I’ve written about the inadequate state of clinical documentation, which is largely unchanged since the days of Osler, (except for a bit more structure introduced by Larry Weed in the 1970s) and was created for billing/legal purposes not for care coordination.

One of the most frequent complaints in my email box these days is a sense that the current record is filled with data, but little knowledge and wisdom. It’s hard to understand each patient’s individual story. Notes are filled with cutting/pasting, inaccuracies, and redundancy. Sometimes among the dozen notes written each day by the medical student, resident, fellow, attending, and consultants there is inconsistency.

The era of Ebola has accelerated the urgency for us to rethink the way we document.

In recent lectures, I’ve called on the country to adopt Wikipedia and Facebook for clinical documentation.

I don’t really mean that we should use those products, but we should embrace their principles.

Imagine if the team at Texas Health Presbyterian jointly authored a single note each day, forcing them to read and consider all the observations made by each clinician involved in a patient’s care. There would be no cut/paste, multiple eyes would confirm the facts, and redundancy would be eliminated. As team members jointly crafted a common set of observations and a single care plan, the note would evolve into a refined consensus. There would be a single daily narrative that told the patient story. The accountable attending (there must be someone named as the team captain for treatment) would sign the jointly authored “Wikipedia” entry, attesting that is accurate and applying a time/date stamp for it to be added to the legal record.

After that note is authored each day, there will be key events - lab results, variation in vital signs, new patient/family care preferences, decision support alerts/reminders, and changes in condition.

Those will appear on the “Facebook” wall for each patient each day, showing the salient issues that occurred after the jointly authored note was signed.

With such an approach, every member of the Texas care team would have known that the patient traveled to Dallas from West Africa. Every member of the care team would understand the alerts/reminders that appeared when CDC or hospital guidelines evolved. Everyone would know the protocols for isolation and adhere to them. Of course, the patient would be a part of the “Wikipedia” and “Facebook” process, adding their own entries in real time.

Yes, there are regulations from CMS enforcing the integrity of the medical record. I’ve had preliminary discussions with folks in government who have signaled that as long as the “Wikipedia” authorship takes place outside of the medical record and then is posted/signed/timed/dated by a single accountable clinician, regulatory requirements will be met. Once posted, the entry cannot be edited/changed, just amended, preserving data integrity.

It’s likely that the “Facebook” portion of the display would not be regulated, but would require the same kind of validation we already do for lab result workflow. The "wall" could also be certified for the Meaningful Use provisions that require viewing of the Meaningful Use Common Data Set.

Once there is a single place for all care team members to look when treating a patient, decision support based on analysis of structured and unstructured data will be easier to engineer.

Although I believe that the medical record coding we do today will become less relevant as we evolve from fee for service medicine to global capitated risk, the use of computer assisted coding and clinical documentation improvement tools will be easier with the “Wikipedia” plus “Facebook” approach.

I can even imagine that emerging Fast Healthcare Interoperability Resources (FHIR) work could represent the “Wikipedia” entry as part of document retrieval standards and the Facebook wall could be part of discrete data query/response, providing a timeline for the key events in a patient’s treatment. I’ve already discussed the need for such timeline data with key FHIR architects.

A team at BIDMC is working on clinical documentation, structured and unstructured, in FY15. We’ll proceed incrementally, learning from each phase, and begin our journey toward an inpatient record that looks more like Wikipedia and Facebook than Osler’s notebook. As Ebola and the tide of EHR dissatisfaction drive innovative documentation thinking, we'll need to move deliberatively.

And if we’re lucky, care team members will rekindle the spirit of working and talking together instead of starting at a screen, checking boxes for Meaningful Use.

Thursday, October 16, 2014

Apple Season continues. This weekend we crushed 152 pounds of apples yielding 8 gallons (2.2 gallons per bushel), down a little from our last crush which yielded 2.4 gallons per bushel, likely because Baldwin apples are less juicy than McIntosh.

The ph was 3.2 (a little more acid than usual) and the specific gravity was 1.050, yielding 6% alcohol.

We’re fermenting this batch indoors since the nightly temperatures in Sherborn are now falling into the 30’s, which can result in a stuck fermentation.

We racked our last cider batch and added malolactic bacteria.

Thus far, our cider production is proceeding flawlessly - with a year of experience under our belt, we’ve found our rhythm.

The Shitake mushroom logs are ready for an enormous fruiting over the next 2 weeks. Unfortunately, I will be in Washington, Philadelphia, Beijing, Qingdao, Shenzhen, Seattle, London, Berlin, Copenhagen, and Amsterdam on the weekends (yes, that’s a lot of red eye flights), so Kathy and I are dividing up the labor, with me doing all the hauling, cutting, and heavy lifting around the farm on the nights I’m there while she takes charge of the mushroom harvest, packaging, and delivery to local farm stands. This is our first year of harvesting commercial quantities of mushrooms, so we’re learning every day.

The hoop house is thriving with the warm days and cool nights of Fall. I’ve picked a peck of peppers (not pickled yet) - hungarian banana, poblano, and japanese chili pepper. Here’s what a peck of peppers looks like:

All the animals are well - the dogs are growing their winter coat, the chickens have molted, the ducks are eating vigorously to prepare for the weather ahead, the alpaca are enjoying sunny cool days, and the bees are completing their winter honey stores (about 70 pounds of honey per hive). My travels begin tomorrow and I’ll be caring for the menagerie by Skype for 4 days.

I suggested that Health IT is in its “trough of disillusionment” moment before it moves toward the “slope of enlightenment”. In the past two weeks, many of my incoming emails have been punctuated with negative feelings about EHRs - Ebola caused by a lack of interoperability, physician/patient relationships strained by the distraction of new electronic workflow requirements, and poor usability. The work ahead is to focus on interoperability, building on the lessons learned and progress made to address key workflow issues.

2017 - providers and individuals send, receive, find, use a basic set of essential health information

2020 - granular information access, expanded uses of information.

2024 - learning healthcare system

This effort will be based on a foundation of standards, certification, security, culture change, and governance.

We broadly discussed the presentation. Commenters described the tension between functional requirements and overly prescriptive standards, the need for innovation and the desire for adoption of mature standards, and the need for privacy and while at the same time fostering increased sharing.

In the afternoon we discussed governance, recognizing that both top down and bottom up models have their supporters. Additional work will be down by the Policy Committee’s HIE Workgroup.

*Focus on Interoperability. ONC and CMS should focus their efforts on interoperability, realizing that healthcare IT stakeholders cannot accomplish every goal simultaneously given limited time and resources
*Industry-Based Ecosystem. A Coordinated Architecture based on market-based arrangements should be defined to create an ecosystem to support interoperability .
*Data Sharing Networks in a Coordinated Architecture. The architecture should be based on a Coordinated Architecture that loosely couples market-based Data Sharing Networks (which might also be called Data Sharing Arrangements)
*Public Application Programming Interfaces (APIs) as a basic conduit of interoperability. The Public API should enable data- and document-level access to clinical and financial systems according to contemporary internet principles.
*Priority API Services. Core Data Services and Profiles should define the minimal data and document types supported by Public APIs.
*Government as market motivator. ONC should assertively monitor the progress of exchange and implement non-regulatory steps to catalyze the adoption of Public APIs.

The group discussed the challenge of focusing on interoperability while also pursing the prescriptive goals of meaningful use. One commenter proposed examining the collective burden/impact of all ONC/CMS requirements and then deciding on phasing.

The group approved these 6 points by consensus as part of a transmittal letter from the federal advisory committees to ONC.

The key takeaway - the approval of these 6 points begins the movement away from a model in which data is extracted from an EHR and then pushed from point to point. Instead the future belongs to real time query of document-based and discrete data from the point of origin where it is stored, to the point of use, such as another EHR, patient mobile device, or population health registry. Standards that are generally used on the internet such as JSON, OAuth, and REST are likely candidates, especially as implemented in FHIR (Fast Healthcare Interoperability Resources).

The next step at the government level is joint federal advisory committee/ONC work over the next 90 days to finalize the roadmap combined with private sector work (industry, standards organizations, academia, patients, providers, payers) to accelerate standards that support the 6 points in Jason Task Force report.

A remarkable day with great energy and enthusiasm to move healthcare toward the same interoperability approach used by Facebook, Amazon, Google, Apple App Store, and most non-healthcare industries. 2015 will be a pivotal year for real time query-based data exchange.

Thursday, October 9, 2014

Mint, one of our pregnant alpacas, had a false pregnancy. Although she gained weight and had all the features of a pregnant camelid, she is no longer pregnant. However, she is 30 pounds overweight and we’ll now have to restrict her access to grain. Time for the alpaca stairmaster.

Mulan, our Harlequin duck with aspiration pneumonia is improving after 10 days on tetracycline. She’s regaining her quack (for almost 2 weeks she’s been voiceless) and is now running with the other ducks. She’s still a bit fatigued, but is on the mend.

It’s apple picking time. My daughter and I picked six varieties of cider apples and organized an apple tasting at the farm to inform our cider making activities.

We decided that Empire was our favorite eating apple, followed by Rome Beaty and Macoun. Our heirloom cider apples - Ben Davis, Northern Spy, and Roxbury Russet were good but had a very firm consistency with a bittersharp taste. Our plan for the upcoming weekend is to crush cider using 1 bushel of Macoun (aromatic), 3 bushels of Baldwin (sweet), 1 bushel of McIntosh (tart), and 1 bushel of crab apples (astringent). Although our apple harvest this year is in the hundreds of pounds, we’ll hopefully have thousands of pounds when the trees mature in 5 years.

Our existing cider fermentation is going well and we have developed a standard process - crush, ferment for 2 weeks, rack, add malolactic fermentation cultures, age for 4 months, bottle, age for 2 months, drink!

As winter approaches, all the creatures of the forest are storing up reserves for winter. The squirrels are storing the acorns that are falling at a fast clip. The bees are stockpiling nectar and pollen. Even the preying mantis (find it in the picture below) are eating their fill.

Leaves are falling, birds are migrating, and mushrooms are popping everywhere.

This weekend (Columbus Day) is all about manure management - moving 10000 pounds of “llama beans” into windrows, a new squash planting area, and our garlic beds. During all that hauling I’ll also move one of our wood chip piles into a new mushroom area using a new technique to first grow Agaricus spawn on cardboard then inoculating chips. I’m hoping for a great spring crop as we expand the number of mushroom species on the farm. Japanese Nameko and Shimeji are my next experiments.

Wednesday, October 8, 2014

How many headlines have you seen over the past month that are either completely false or a vast oversimplification of complex issues.

As I tell my staff, there is no problem that cannot be morphed into an IT shortcoming.

There a point at which CIOs, EHR vendors, and those working on policy feel like each day is spent being thrown under a bus.

The journey of the last decade has been the continuous progression of technology, policy, and cultural change that has moved us from 10% adoption of EHRs to over 70%.

In Massachusetts, millions of transactions are exchanged for care coordination, population health and quality measurement every month.

Web-based, mobile friendly, cloud hosted products are either live or soon to be live from all the leading EHR vendors.

Am I satisfied with our position? No. We still have work to do.

Am I satisfied with our trajectory? Absolutely. There is a pace of cultural readiness that cannot be accelerated if adoption is our measure of success. Alignment of economic incentives, public education, and the evolution of technology are necessary pre-requisites for change.

When I was growing up in Southern California, I remember dropping envelopes into the Diebold "after hours" bank repository. Then one day, a machine became available that automated transactions with that one branch of that one bank.

A few years later, those machines worked with all branches of that one bank.

A few years later, those machines worked across different banks in California.

A few years later, those machines worked across the country.

A few years later, those machines worked across the globe in multiple currencies.

Automated Teller Machines evolved over time to address growing demands once workflow redesign, changes in consumer expectation, and worldwide network enablers were in place.

EHRs are in the biplane era and we’ve not yet invented jet engines, but we’re working on them.

We cannot go directly from horse drawn carriages to the Dreamliner.

I’m optimistic.

At the October 15, 2014 joint meeting of the Standards and Policy committees we’ll review the JASON report which will emphasize the need for open EHR Application Program Interfaces (APIs) without impediments (such as high fees) to data exchange.

HL7 is likely to have the necessary Draft Standards for Trial Use (second version of FHIR) by mid 2015.

Meaningful Use Stage 3 is likely to focus on interoperability.

So instead of a view from under the bus, it’s time for everyone to recognize the progress we’ve made, acknowledge the hard work ahead, and agree that there are unemotional next steps to address specific needs in specific timeframes.

I’ll do my best to educate all those stakeholders and journalists who focus on the absence of flying cars instead of the fact that horses have already turned into Teslas.

In March, I’ll add 4 ounces of dextrose for a slight effervescence (2.5 VCO2) and bottle it in swing top 16 ounce containers.

Best consumption will be in Fall 2015.

For the holidays, we’ll toast with the cider we made last winter.

On the animal side, we continue to wait for our next baby alpaca. There are only two possibilities - a false pregnancy (possible but unlikely) or an extra long gestation. Alpaca typically have an 11.5 month gestation but 15 months is possible. A baby born in winter would require the use of a “cria coat” - a down jacket for the baby. We’ll see. The barn loft is now filled with 300 bales of second growth hay. Grain and alfalfa are fully stocked for winter. The heated buckets are in place and we’ve touched up the windows/paint in the barn to keep everything warm.

Our duck with aspiration pneumonia continues on antibiotics and is still breathing hard. It’s hard to find a duck specific veterinarian, but our large animal vet will visit next week for alpaca mom/baby care and will spend time with the poultry.

The work of the farm is slow evolving from harvest to winter planting, from forest management to wood splitting, and from outdoor projects to indoor projects.

We’ll complete the construction of the walk in refrigerator this weekend just in time for the flood of mushrooms that will be ready. The oyster mushrooms have fruited like clockwork - golden oyster in August, Italian Oyster in early September, Gray Dove in mid-September, and Polar White in late September. The remaining 7 varieties are cold loving so they’ll fruit in October. We’re expecting 100’s of pounds.

I’ve been harvesting a few pounds of Shitake each day and they’ve been in lunchtime mushroom soup and dinner stir frys.

We’ll have more bee work this weekend, feeding the bees our homemade “bee tea” during the nectar nadir. One of the hives was weak and we consolidated two hives together to give them critical mass for the cold days ahead.

Wednesday, October 1, 2014

On October 15, the Policy Committee and Standards Committee will meet to review the draft interoperability roadmap that will guide our work in the post Meaningful Use era.

The draft to be presented is a work in process and will be iteratively improved over the next 4 months with multi-stakeholder input. Clarifying the Modern Healthcare story, October 15 will include a straw man for Federal Advisory Committee reaction, not a finished plan.

We’ll also hear an important presentation from the JASON task force, translating the general recommendations in the JASON report into actionable policy and technology next steps, especially around the need to extend interoperability from the sending/receiving of CCDA documents to also enable the data-element level query capabilities of well defined, secure application programming interfaces (APIs), likely using HL7’s Fast Healthcare Interoperability Resources (FHIR).

Meaningful Use Stage 3 regulations are currently in draft and will be released as NPRM before the end of the year. My hope for these regulations is that they will be less prescriptive than previous stages, reducing the burden of implementation for providers and vendors.

It’s purely my opinion, but I’m optimistic that simplification will happen, given that the 2015 Certification Rule is likely to decouple Meaningful Use and certification. Certification is likely to be incremental year to year without the tidal wave of requirements we’ve seen in the past. Certification of health IT (not just EHRs) will be with us for a long time and may be leveraged by more programs than just the EHR incentive programs. Imagine that modules for patient generated data (such as wearables), health information exchange (HISPs), and analytics services (such as those used for care management by ACOs) could be certified and used in any combination to achieve outcomes.

I look forward to a future of FHIR-based APIs with security enforced via OAuth2 and transport facilitated by RESTful approaches as the Meaningful Use program ends and ONC moves forward with its mission to improve quality, safety and efficiency, using policy and technology levers that enhance interoperability.